Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure that two residents were free from physical abuse when an altercation occurred between them. On the specified date, one resident, who had a history of severe cognitive impairment, mental health conditions, and episodes of aggression, entered the main dining area and pulled another resident's ear. The second resident, also with severe cognitive impairment and a diagnosis of Alzheimer's disease, responded by biting the first resident on the right wrist. Both residents had documented histories of behavioral issues, including aggression and non-cooperation with care, as noted in their care plans and assessments. Staff interviews revealed that the two residents were known to have frequent verbal and physical altercations, with some staff reporting that such behaviors occurred almost daily. However, other staff and the DON stated that it had not been reported that these altercations happened daily. On the day of the incident, staff immediately separated the residents and assessed them for injuries. The first resident sustained a small bruise to her right wrist, while the second resident had no injuries. The incident was documented, and the appropriate parties were notified as per facility policy. The facility's policies required staff to protect residents from abuse, including abuse from other residents, and to investigate and report all altercations. The care plans for both residents included interventions such as medication administration, behavioral monitoring, psychiatric consults, and separation of residents when necessary. Despite these measures, the altercation occurred, indicating a failure to prevent resident-to-resident abuse as required by facility policy and regulatory standards.